Norwalk Agent

Dr.T.V.Rao MD

Dr.T.V.Rao MD 1
History of Norovirus

The Norovirus was originally named the
Norwalk agent after Norwalk, Ohio, USA,
where an outbreak of acute gastroenteritis
occurred among children at Bronson
Elementary School in November 1968. The
name was shortened to Norovirus after being
identified in a number of outbreaks on cruise
ships and receiving attention throughout the
USA. In 1972, electron microscopy on stored
human stool samples identified a virus,
which was given the name
Dr.T.V.Rao MD Norwalk virus. 2
 Norovirus

 Norovirus (formerly Norwalk agent) is an RNA
virus (taxonomic family Caliciviridae) that causes
approximately 90% of epidemic non-bacterial
outbreaks of gastroenteritis around the world, and
may be responsible for 50% of all foodborne
outbreaks of gastroenteritis in the US. Norovirus
affects people of all ages. The viruses are transmitted
by faecally contaminated food or water, by person-
to-person contact, and via aerosolization of the virus
and subsequent contamination of surfaces

Dr.T.V.Rao MD 3
Norovirus
Formerly called
Norwalk-like Virus
Highly contagious
Cause of 50% of all
foodborne
outbreaks of
gastroenteritis
Able to survive
freezing and high
temperatures

Dr.T.V.Rao MD 4
Norovirus are Diverse Group
 Norovirus (NoV) are a 
genetically diverse group of
single stranded RNA,
nonenvelopedd viruses
belonging to the
Caliciviridae family.
According to the
International Committee on
Taxonomy of Virus, the
genus Norovirus has one
species, which is called
"Norwalk virus" and
assigned the abbreviation
"NV". Serotypes, strains and
isolates include: Dr.T.V.Rao MD 5
 Norovirus Characteristics

Highly contagious
Multiple modes of transmission
Stable in the environment
Resistant to routine disinfection methods
Carriers may not be symptomatic

Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.
Dr.T.V.Rao MD 6
 Norovirus characteristics

 Cause epidemic gastroenteritis
 Replicate in human intestinal mucosal cells to
produce gastroenteritis
 Human Norovirus not generally able to be grown in
culture yet
 Mechanism of pathogenicity still unknown
 Genetically variable: many distinct human strains in
2 major genogroups
 Norovirus characteristics cause limitations for
detection methods
Dr.T.V.Rao MD 7
 Norovirus Infection

 Infectious dose of 10-100 virus particles
 24-48 hour incubation period
 12-60 hour duration of illness
 A ―mild‖ and short-lived illness
 Treatment may indicate IV fluids
 Viral shedding of 3 weeks or more

Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.
Dr.T.V.Rao MD 8
 Outbreaks of Norovirus

 Outbreaks of Norovirus infection often occur in
closed or semi-closed communities, such as long-
term care facilities, overnight camps, hospitals,
prisons, dormitories, and cruise ships where the
infection spreads very rapidly either by person-to-
person transmission or through contaminated food.[
Many Norovirus outbreaks have been traced to food
that was handled by one infected person

Dr.T.V.Rao MD 9
Why is Norovirus so infectious?

 High attack rate (> 50%) and low infective dose (10-100
particles)
 Viral load may be >107/g faeces
 Viral shedding can occur for > 14 days
 Little or no immunity following infection
 Environmentally tough - resistant to acid, heat,
disinfectants, chemicals, drying etc.
 Secondary person-to-person spread via vomit, aerosols
and fomites
Dr.T.V.Rao MD 10
 Pathophysiology


 When a person becomes infected with Norovirus, the
virus begins to multiply within the small intestine.
After approximately 1 to 2 days, Norovirus
symptoms can appear. The principal symptom is
acute gastroenteritis that develops between 24 and
48 hours after exposure, and lasts for 24–60 hours.
The disease is usually self-limiting, and
characterized by nausea, vomiting, diarrhea, and
abdominal pain; and in some cases, loss of taste.
General lethargy, weakness, muscle aches, headache,
and low-grade fever may occur.
Dr.T.V.Rao MD 11
 Criteria for Norovirus infection


 Stool culture negative for bacterial pathogens
 Mean duration of illness 12-60 hr
 Vomiting in > 50% of cases, (more common in children
whereas adults have diarrhoea).
 Projectile vomiting often a characteristic symptom
 Incubation period is 24-48 hr but may be 10 - 50hr
 Previously no diagnostic methods were available so
commonly known as acute non-bacterial gastroenteritis
Ref: Kaplan et al. Am J Pub Health 1982;72:1329-32)

Dr.T.V.Rao MD 12
 Transmission

 Fecal-oral route
 Indirect contact with
the virus on
contaminated surfaces.
 Via contaminated food
and water
 Shellfish from sewage
contaminated water

Dr.T.V.Rao MD 13
 Food Handlers and
Norovirus

 Persons working with food who are sick with
Norovirus gastroenteritis are a particular risk to
others because they handle the food and drink many
other people will consume. The virus is very small
and shed (discharged from the body through vomit
or stool) in great numbers. Thus—without meaning
to—a sick food handler can easily contaminate the
food he or she is handling. Many of those eating the
contaminated food may become ill, and an outbreak
may result.
Dr.T.V.Rao MD 14
 Norovirus Transmission

Transmission

 ―Oral-fecal‖ route
 Food (39%)
 Hands, person-to-
person (12%)
 Water (3%)
 Also environmental
surfaces: carpets,
toilets, etc.
Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.
Dr.T.V.Rao MD 15
 Modes of Transmission by Food


Food sources (i.e., food arrives contaminated)
Preparation
Food handlers
Customers
Most at risk: ready-to-eat foods that require
handling but no subsequent cooking (e.g.,
salads)
Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.
Dr.T.V.Rao MD 16
 Susceptibility of Norovirus

 Norovirus is rapidly
inactivated by either
sufficient heating or by
chlorine-based
disinfectants, but the
virus is less susceptible
to alcohols and
detergents as it does
not have a lipid
envelope.
Dr.T.V.Rao MD 17
 Symptoms

Symptoms usually start within 24 to 48 hours after
exposure.
Vomiting
Watery diarrhea
Stomach Cramping.
Low grade fever occurs in half of cases

Dr.T.V.Rao MD 18
 Norovirus Infection Symptoms


Vomiting
Diarrhea
Nausea
Abdominal cramps
Headache, muscle aches
Fever (minority)
Dehydration
Up to 30% may be asymptomatic

Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.
Dr.T.V.Rao MD 19
 Specific Diagnosis

 Specific diagnosis of
Norovirus is routinely
made by polymerase
chain reaction (PCR)
assays or real-time PCR
assays, which give
results within a few
hours. These assays are
very sensitive and can
detect concentrations as
low as 10 virus particles
Dr.T.V.Rao MD 20
Scheme for molecular detection of
Norovirus
Specimen Processing (Faeces)

Viral Recovery & RNA extraction

Generate cDNA from RNA by reverse transcription

Amplify by real-time PCR

Norovirus Genogroup I or II identified

Sequencing

Genotyping
Molecular tools for tracing sources of
infection: : Norovirus Genotyping

 Sequence Norovirus PCR product from faeces

 Compare sequence with similar sequences in CDC &

other databases and determine % similarity between
Norovirus DNA sequences

 Only short DNA fragments are compared (100-200 bp)

not whole virus genome

 Compare prevalent outbreak strains with strains

occurring at same time in NZ & internationally
Dr.T.V.Rao MD 22
 Treatment

There is no specific treatment.
Persons with diarrhea and/or vomiting
should drink plenty of liquids to prevent
dehydration.
Medications, including antibiotics (which
have no effect on viruses) and other
treatments, should be avoided unless
specifically recommended by a physician.
Dr.T.V.Rao MD 23
 Control of Norovirus outbreaks

 Secondary spread via aerosols & vomit is a major problem
 Isolation of patients, staff and infected areas
 Staff may excrete noroviruses for up to 14 days – should
they be checked for clearance?
 Thorough surface cleaning (benches, taps, fomites,
furniture, floors etc.)
 Good hand washing practices: some hand disinfectants are
not effective for all viruses
 Refer specimens for viral analysis and genotyping to help
track movement of epidemic strains

Dr.T.V.Rao MD 24
 Clean and disinfect
contaminated surfaces

 After an episode of
illness, such as vomiting
or diarrhea, immediately
clean, disinfect, and rinse
contaminated surfaces.
Use a chlorine bleach
solution with a
concentration of 1000–
5000 ppm (5–25
tablespoons of household
bleach [5.25%] per gallon
of water)

Dr.T.V.Rao MD 25
 Caring the laundry procedures

 Linens (towels,

tablecloths, napkins) and
clothing that are soiled to
any extent with vomit or
stool should be handled
carefully—without
agitating the item—to
avoid spreading virus.
The items should be
laundered with detergent
at the maximum available
cycle length and then
machine dried
Dr.T.V.Rao MD 26
Hand Washing Still the best option
to prevent infection
 Wash your hands carefully

with soap and water,
especially after using the
toilet and before preparing
or handling food. Norovirus
are found in the vomit and
stool of infected people from
the day they start to feel ill,
and the virus continues to be
present in the stool for as
long as 2 to 3 weeks after an
infected person feels better.

Dr.T.V.Rao MD 27
 Care of the Hands Reduces
Norovirus Infections

 Continued care in
washing hands is
important in preventing
the spread of this virus.
Alcohol-based hand
sanitizers (containing at
least 62% ethanol) may be
a helpful addition to hand
washing, but they are not
a substitute for washing
with soap and water
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 CDC guidelines for
Norovirus Prevention
 The guidelines include

recommendations related to
patient cohorting and
isolation precautions, hand
hygiene, patient transfer and
ward closure, indirect
patient care staff,
diagnostics, personal
protective equipment,
environmental cleaning,
staff leave, visitors,
education, and
communication.
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 
Created by Dr.T.V.Rao MD
for ‘e’ learning resources for
the Medical Professionals in
Developing World
 Email
 doctortvrao@gmail.com

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